Healthcare Provider Details

I. General information

NPI: 1417956772
Provider Name (Legal Business Name): MICHAEL TODD BOGGS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GRAND AVE
DAYTON OH
45405-7538
US

IV. Provider business mailing address

405 W GRAND AVE
DAYTON OH
45405-7538
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-3276
  • Fax: 937-723-3277
Mailing address:
  • Phone: 937-723-3276
  • Fax: 937-723-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-06-7136
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.067136
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: